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A Process-based Approach to Fixing Healthcare - Interview with Steven Spear What can be done to fix healthcare? In this Process Excellence Network interview, author and MIT Professor Steven J. Spear, talks to PEX Network’s editor Diana Davis about how the healthcare system is broken and offers his perspective on what it will take to mend it.PEX Network: You’ve done a lot of work on healthcare improvement, a lot of workin the healthcare field. Is healthcare broken?Steven Spear: It is.PEX Network: How?Steven Spear: The problem healthcare has, in some ways, is that it’s a victim of its ownsuccess. What I mean by that is that, traditionally healthcare was delivered by the solepractitioner. The reason that was the case was that healthcare science was sounsophisticated and poorly advanced, that really, the moment of magic was theinteraction between the patient and the doctor. And so healthcare built up organizationsin support of that moment of encounter between the patient and the doctor. Whathappened then, and this happened fairly recently - in the last 20, 30 years at most - isthat the healthcare sciences have proliferated. So there are disciplines now which didn’teven exist 30 years ago. And the depth of knowledge has increased exponentially insome of those disciplines.So, now when you go to treat an illness, deal with a condition, treat an injury it’s nolonger the patient interacting with a sole healthcare professional, but actually within anentire system of people – doctors, nurses, pharmacists, different types of technicians,medical assistants, secretaries, etc. There could be dozens and dozens of people just forprimary care and it takes something really challenging like dealing with cancer, and youcould be dealing with many dozens of people over the course of treatment which couldrun weeks, if not, months.PEX Network: So would you say it became like a big corporation where you’ve gotreally a siloed approach?Steven Spear: Well, that’s exactly what’s happened. So, traditionally, doctors andnurses also were trained separately and doctor’s work was doctor’s work and nurseswork was nurses work. And so you had this approach of training people within theirdisciplines, within their functions and then employing them also in silos, within theirdisciplines, within their functions. If you walk into a typical hospital now and look at adirectory, everything is by the silo of discipline and specialty even though the care isprovided ways which have to cross all those boundaries which separate one disciplinefrom another.

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PEX Network: What’s the starting point for fixing that?Steven Spear: Right, so I’d say there’s an internal and external starting point. Theinternal starting point is for senior leadership of healthcare providing organizations torecognize that managing functions and specialties is just part of what they need to do.What they need to do is manage the process of care delivery and so that would start withdefining work, not just by the function and the specialist, but by the service line, so start-to-finish, end-to-end, stem-to-stern path or trajectory that patients experience, going frominjured or ill to better and well.PEX Network: But are there major cultural stumbling blocks to achieve that?Steven Spear: Oh, yes, there are lots of them. From the very beginning, people aretaught within healthcare that they’re an independent professional. And you see this inevery step along the way. So, I’ll give you one example. So I was following some surgicalresidents on rounds, they check on their patients at something like five or six in themorning. And the people I was watching were all thoracic surgeons. So, to reallyemphasize the silo or stovepipe approach to managing care. First the interns arerounded to check on the patients and they report it out to the residents who report it outon another set of rounds, so the chief resident who finally reported out to Fellows and theattending physicians – that was within thoracic surgery.Now we happen to be bed side at the third or fourth pass on patients. And again, thatapproach makes perfect sense if you exist in a world of craft and master craft people andprofessional development through mentorship and apprenticeship. So you do your workand you get it validated and it keeps popping up so you have the attending physicianwho is the master craft and sort of the Yoda of the relationship. So, we’re leaving apatient who’s had one surgery and because it’s an older patient, after the thoracicsurgeons leave, a psychiatrist comes in because there’s some issues related todementia. And this attending physician and psychiatrist is followed by a Fellow and achief resident, residents and interns and a gaggle of little ducklings or geese followingalong.And so he does his pass on this patient and then someone else comes in and it’s anattending physician in cardiology because she also has heart problems and circulatoryproblems. So he does his pass with his Fellow and chief resident, resident, and at nopoint does any of them talk to each other about the patient.And then separate from that, there’s a whole group of nurses who are responsible for themoment-to-moment care of this patient who are having their own set of rounds and theirown set of discussions and hand-offs across shifts not talking to the doctors. Now there’smanaging the pieces, but no one has defined a process and tried to integrate the piecesinto a coherent system.PEX Network: It sounds to me that there are two competing concerns there - firstmaking sure that junior doctors aren’t left in charge of a patient on their own and,secondly, making sure that they learn. How would you balance those competingdemands?Steven Spear: Right. So there are a couple of things you can do here. One is this notionthat people learn a profession, set of skills through practice and then through coachpractice – that makes perfect sense. That’s how we learned how to speak, how to use a

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fork and knife, how to ride a bicycle, swim, whatever it is. So that basic notion of learn-by-coach-doing makes sense. And then again, with the possible exception of learning towalk, I can’t think of a human skill we have which didn’t involve some sort of coaching.There’s another piece to this, though. I teach at MIT and, of course, there are a lot ofscience and a lot of engineering students. Our students in engineering know, I think,from the get-go that they’re learning a skill set, mechanical engineering or electricalengineering, aerospace engineering, whatever it happens to be, in order that they cancontribute to projects much larger than themselves. And I don’t think beyond thefreshman year they ever think that they will design anything sophisticated and complexby themselves or with their friends just from within a department. They know, even atthat level, that they have to understand how systems of work come together becauseanything they design that will finally make its way into the marketplace will be the workacross all these different specialties and disciplines. So that’s engineering.Healthcare, they’re not trained that way - to think of themselves as deeply skilledprofessionals who contribute to a system much bigger than themselves. And I’ll give youone example of that. I have a friend, Alan, and he was complaining that he discovered athis hospital that if a certain number of his patients develop surgical site infections in ayear, that he would lose his privilege to perform surgery at that hospital, whichessentially is his income, right. And he was complaining about how unfair that was. Now,you and I as laypeople say, Alan, patients don’t want to get surgical site infections – isn’tthat fair? He said, well, here’s the thing – the surgery I do, maybe it runs 30 minutes, anhour, three hours, four hours of really complex work. But that patient has been in thesystem for days before I touch them, will be in the system for days, if not, weeks andmonths after I touch them, and all these points of contact over these hours, days andweeks is an opportunity for an infection to occur; for an infection to be sustained andnurtured and grow out of control. He says, not only can’t I control that, I never even seethose things, yet I’m being held responsible.It’d be like holding the junior engineer who’s designing a single component on an aircraftfor the performance of the aircraft as a whole, rather than what would happen in Airbus,Boeing, Ford Toyota – holding the chief engineer responsible for the integration of theparts into his system.PEX Network: So, effectively, this comes back to the whole, that healthcare [as asystem] is broken. None of these parts are all working together as part of acohesive whole?Steven Spear: That’s right, that’s right.PEX Network: In other work that youve done you talk about what it takes tobecome a high-velocity organization – is there such a thing or can there be such athing as a high-velocity healthcare organization?Steven Spear: Absolutely. The term high-velocity organizations, refers to thoseorganizations which have achieved exceptional levels of performance. I didn’t call themgreat companies or high-performing companies because the pattern is consistent tomost outstanding organizations in many different industries. It could be high-tech likesemi-conductors, it could be auto services. What matters is that they achieve theirposition of leadership through exceptional rates of sustained improvement and internally-

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generated innovation - the velocity of getting better leads to the point of being ahead ofthe pack.Within healthcare, what we’ve seen is that certain organizations, which have started totake on a more mature, more sophisticated view of designing, operating and improvingsystems have been able to do remarkable things: eliminate complications like patient fall,central line infections, surgical site infections, missed medication, wrong site surgery. Atcertain organizations those things have disappeared. Now, when those things disappear,the cost of providing healthcare go way down, the cost of human suffering, financial costof dealing with complications, and so on and so forth.The other thing is when you start creating systems with an eye towards what are theparts and how they relate to each other, you lose a lot of the inefficiency of things whichare designed which don’t mesh properly. For example, when we first started this work,which was about ten years ago, I remember being in a conference where the surgeonsays, "son-of-a-gun, I get it! We spend so much time individually creating value and wedestroy it in the hand-offs."Well, destroying value in the hand-offs means that you have rework, you have time loss,money lost, quality of care lost. But if you create a system and you create value and thenhand it off and someone else is adding to the value rather than having to recreate thevalue, not only do you increase quality, but you reduce cost, increased capacity, so onand so forth.My friends who were really adamant about trying to bring system thinking - the realdiscipline about designing, operating and improving systems into healthcare – they sayhealthcare can handle twice the patients at half the cost.PEX Network: Amazing. And are there specific things that some organizations aredoing that seem to really be about sending them towards this goal?Steven Spear: Right. So I’d say there were three distinct things. One is structural; one isdynamic; one is leadership.The structural issue is actually starting by defining and designing systems of processesstart-to-finish, end-to-end, stem-to-stern out of the currently disconnected pieces. So, forexample, you walk into most hospitals and you’ll find there is a department of radiology,orthopedics, orthopedic surgery, medicine, pharmacy, nursing, etc., etc. Very rarely willyou discover that there’s a service line defined for new repair as opposed to hip repairand shoulder repair, where somebody’s actually responsible for bringing all of thesethings together.So, step one is creating some structure out of the discombobulated parts – that’s one.Then there’s the dynamic piece which is, and it gets back to this issue of high-velocity,that when you’re trying to design things which are complex – I think we all know this fromour own personal experience, the first time is going to be imperfect. For some reasonyou get it wrong. So characteristics of the high-velocity organizations, is that when theybuilt process, they wrap the process in constant learning. They’re very, very attuned tothings going wrong, abnormalities which they hadn’t expected in their initial designbecause this is not what we predicted; this is not what we expected. We have to figureout why things are surprising us so they can be less surprising, more reliable, higher jobgoing forward.

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So if one piece is a structural response of creating process, creating system out of parts;the second is a dynamic response of wrapping, incorporating learning into the part ofdaily work. And it’s that you treat patients, but you treat patients and learn how to treatpatients better tomorrow than you did today. So that’s the second piece.And then there’s a third piece – the third piece is leadership. What we find both withinand outside of healthcare is that organizations which struggle, is that leaders think thatoperational excellence, process excellence, system design and management issomething to be delegated away from the managerial concerns of finance strategy andthat sort of thing. The organizations which really excel make sure that processexcellence is at the C-Level of the organization, that the basic skills of how do youdesign, operate, improve complex work for it has a very high velocity improvement andinnovation, that that’s a concern, a worry, a daily responsibility of the senior leadership toresolve the structural and the dynamic issues.PEX NetworkI invite you to join as a member of the PEX Network Group http://tinyurl.com/3hwakem,you will have access to Key Leaders Globally, Events, Webinars, Presentations, Articles,Case Studies, Blog Discussions, White Papers, and Tools and Templates. To accessthis free content please take 2 minutes for a 1 time FREE registration athttp://tiny.cc/tpkd0PEX Network, a division of IQPC, facilitates access to a wealth of relevant content forProcess Excellence, Lean, and Six Sigma practitioners. Further enhanced with an onlinecommunity of your peers, we will provide you with the tools and resources to help youperform more effective and efficiently, while enhancing the quality operations within yourorganization. As our industry becomes more and more dependent on the Web forinformation, PEXNetwork.com has been developed to provide Six Sigma professionalswith instant access to information. Leveraging our strength and foundation in education,IQPC and the Process Excellence Network are uniquely positioned to provide acomprehensive library of webcasts gathered from our events, as well as exclusivecontent from leaders in the industry.Editor’s Note: The transcript of the video interview Fixing Healthcare: Interview withAuthor Steven Spear, filmed on location at PEX Week Orlando January 2011.